Provider Demographics
NPI:1164569091
Name:BOURNE, JEFFREY PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:PHILIP
Last Name:BOURNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1811 WILSHIRE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5626
Mailing Address - Country:US
Mailing Address - Phone:310-453-9010
Mailing Address - Fax:310-828-3661
Practice Address - Street 1:12555 W JEFFERSON BLVD STE 302
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-7032
Practice Address - Country:US
Practice Address - Phone:424-443-5600
Practice Address - Fax:424-443-5600
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66931208000000X
CAG86941208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics